Health care close to home.

Alaskans are finding they don't have to go thousand of miles - and incur high travel costs - to get medical attention. Health care is increasingly available in Anchorage, in regional medical centers and even in more remote Bush areas.

Changes in Alaska's health care system are bringing more medicine closer to home - whether home is Anchorage or Aniak. That's a relief to families of people who get sick, and it's keeping more dollars in Alaska.

When one member of a family gets sick and has to travel out of town for care, others in that family have to spend money on travel, hotels and restaurant meals, as well as lose time at work.

"You have to look at the total cost of the illness - and that's the impact on the family, not just the individual," says Harlan Knudsen of the Alaska Hospital and Nursing Home Association. The mental strain of being far from home can also retard the healing process.

Despite the sparse population, Alaskans are building one of the best rural health care systems in the nation, Knudsen and others agree.

Services to Alaska's Bush communities are being improved as regional centers convert from government operation to control by local Native nonprofit groups. Community health aides, Alaska's version of China's "barefoot doctors," are getting more training and support as they work directly with the people in their villages.

Meanwhile, in Anchorage, Alaska's traditional health care hub, services now rival those available Outside.

"Basically, every acute or tertiary care service that's available in the Lower 48 is available at Alaska Regional Hospital," says Lyn Whitley, marketing director for that 238-bed operation.

Alaskans still must travel Outside for organ transplants, and that's not likely to change in the near future, given the specialized procedures and Alaska's distance from many potential donors.

Anchorage Advances

But services short of that are available here and now. Alaska Regional just added a special operating room that's reserved strictly for open-heart surgery, and a Level 3 neonatal care unit will provide for newborn infants who need intensive care.

Virginia Collins, program director for the in-patient rehabilitation unit at Alaska Regional, recalls her time as a medical management consultant in 1975.

"Then," she says, "at least 85 percent of the patients who needed almost any extensive treatment or therapy had to go outside the state." That situation has changed dramatically, and now, she says, "We're really better off than a lot of other states."

Over at the newly renamed Providence Alaska Health Center (formerly Providence Hospital), new technology goes hand in hand with extra efforts to keep people well instead of treating them after they get sick, says Leslie Lancaster of the Providence marketing department.

Providence pediatricians can sample a fetus' blood, do blood transfusions and medicate the fetus right in the womb, Lancaster adds.

Women can get breast biopsies in half an hour - and without general anesthesia - with a new procedure that shoots a hollow needle into the area that needs to be checked. Providence is one of only five teaching centers in the country for that procedure, Lancaster says.

Those sorts of services reduce the number of people in the hospital, but health care businesses here are viewing that as a challenge rather than a drawback.

"Our census (at Providence) has been going down," says Lancaster. "We're adjusting the way we deliver patient care. People want to go home, and that's the direction we are heading."

Patients can now receive intravenous chemotherapy, full physical therapy and mechanical breathing help without spending their time in the hospital. It cuts costs and makes the patients happier.

Alaska Native Medical Center (ANMC) provides a host of programs to serve Natives across the state and serves as a teaching facility as well. The new center being built at Tudor and Bragaw in Anchorage will provide state-of-the-art facilities for the doctors who practice there.

Changes for the Bush

But the big changes in Native health care are happening farther afield. Facilities such as the big new center at Kotzebue are part of the change, but improvements in health care are coming along in other regional centers as well, and the community health aide program, started in 1968, has made major strides in the last few years.

Dr. Rob Burgess at ANMC says the health aide system was in crisis in 1988, with health aides burning out at an alarming rate.

In response, salaries were increased, and the aides were given more help and training to cope with the needs in their communities. The statewide budget for the program grew from about $5 million to nearly $20 million over the last few years, Burgess says. The aides now get 16 weeks of training in four-week increments, he says, either at ANMC or at regional training sites, rather than just a few weeks of instruction before returning to the villages to care for people.

It generally takes two or three years for community health aides to complete the training program and become designated as community health practitioners, Burgess says, but they are never away from their villages for more than four weeks at a time. Some training is provided long-distance by computer, and a new handbook was prepared for the aides two years ago.

There are now 178 community health clinics across the state, with most of them having two or more health aides to provide some relief from being constantly on call.

A broader change is the new system of "compacting," in which the Indian Health Service (IHS) contracts with Native groups to provide services.

That system "is really going to change the way health care is provided out in the Bush," says Deborah Erickson, chief of community health services for the state's Division of Public Health. "What's scary for some people is there won't be the IHS oversight there used to be.

"But I think we'll see an increase in Native people trained as health professionals, and I think they'll be trained to higher levels. Advancing the education of health aides to physician assistants would really increase the level of care in the rural areas."

Community Care

Growth in medical services and employment is evident in the Yukon-Kuskokwim Delta and in southeast Alaska, where two Native non-profit health corporations have expanded rapidly since taking over operations under the Indian Self-Determination and Educational Assistance Act.

That 1975 law essentially says that Indian tribes or tribal organizations can contract with the federal government to operate any programs that otherwise would be run by the government for them. The government must provide the same amount of money that was being spent for the service before the change.

"In 1986, when we signed the contract (with IHS), we had 220 employees," says Art Willman, vice president of operations for the Southeast Alaska Regional Health Consortium. "Now there are 650."

Out in Bethel, the Yukon-Kuskokwim Health Corp. has the biggest contract in the nation with IHS, says Ed Hansen, vice president for hospital services there.

The 55-bed Y-K Delta Hospital went from 14 docs under IHS to 24 physicians now, Hansen says, partly because collections from third-party payers (meaning insurance companies, Medicare and Medicaid) rose from virtually nothing to about a third of the hospital's operating budget of $27 million.

"Any money we collect from third-party reimbursement allows us to increase services to our patient population," Hansen says. "I think the IHS built up an outstanding system over more than 20 years, but it was run by expatriates. Now, decisions around the philosophical nature and scope of the system are made by the Native owners, if you will, of the delivery system."

One example, he says, is the directive to build up local service facilities to keep people on the Delta, "whereas the federal system may have seen us as a triage point for moving them on to ANMC."

The health corporation is building subregional clinics across the Delta so that people in the villages won't have to come to Bethel for services.

"Community health aides are our first responders, and they do a wonderful job," Hansen says, "but they cannot provide many of the services that require a mid-level practitioner or a physician. By moving physicians or mid-level practitioners to the clinic, we can avoid trips to Bethel."

Each of the 24 doctors at the hospital works in the villages for at least two weeks a year, Hansen says, and the corporation is moving toward group practices in which the same physician will treat people from a particular village - whether they're being seen in Bethel or in the villages. That step will increase confidence in the doctors and improve care, he says.

In another move to keep patients on the Delta, the hospital is contracting with ANMC so that specialists travel to Bethel for their surgeries, rather than sending the patients to Anchorage.

"That evolution began about two years ago," Hansen says. "There's an attitude shift occurring at ANMC - they are becoming more of our tertiary care facility than in the past." Orthopedic surgery will be performed at the Y-K hospital starting in September, he says. "That's another significant step toward keeping our patients here instead of sending them to Anchorage."

The same thing is happening in the Southeast health care system, says Willman in Sitka.

"In the olden days, we didn't have a pediatrician. Now we do. In the olden days, those cases had to be transferred to Anchorage or Seattle," he says. "We are able to do more specialized surgery here - for example, we have an ENT (ear, nose and throat) surgeon who spends several weeks a month here. ... We've gotten into telemetry, and we monitor a lot more patients here that would have to be sent out."

The corporation is making a big push to improve the "continuum of care" from the village clinics on up, Willman says. "We assign a physician to be a family doctor for each of our communities. That person makes the field trips, looks over the shoulders of the health aides, and follows the cases."

In Southeast, the turnover in community health aides has been low, Willman says, and some have been on the job for 20 years or more.

"They have more evaluation skills, and they're handling more complex kinds of screening," he says. "They're also able to do a lot more teaching of personal health skills - use of diabetes medicines and that sort of thing. Some go to schools and do some basic health and hygiene teaching.

"There has been traditionally a high regard for the health aides," Willman says. "We call them the backbone of our program. They're right out there."